Diabetic Foot Ulcers

Wound Home Skills Kit: Diabetic Foot Ulcers

AMERICAN COLLEGE OF SURGEONS DIVISION OF EDUCATION Blended Surgical Education and Training for Life® SAMPLE

Welcome We want to help you learn as much as possible about how to care for your diabetic foot ulcer. The American College of Surgeons Wound Home Skills Program was developed by members of your health care team: surgeons, nurses, wound care specialists, and patients. You are also an important member of your health care team. This booklet will help you learn and practice the skills you need to keep your feet healthy, take care of your ulcer, and watch for improvements.

Your Diabetic Foot Ulcer ...... 3–10

Treatment ...... 11–16.

Wound Care ...... 17–30.

Negative Pressure Wound Therapy ...... 31–38

Resources ...... 39–48

Watch the accompanying skills videos included online at facs.org/woundcare Your Diabetic Foot Ulcer

Definition and Causes Testing and Diagnosis What Is a Foot Ulcer? ...... 4 Tests and Exams ...... 8 What Causes Diabetic Foot Ulcers? ...... 4 How Severe Is Your Foot Ulcer? . . 5 Wagner Classification System for Diabetic Foot Ulcers ...... 6 Your Diabetic Foot Ulcer 4 2 3 SAMPLE These ulcers can also occur on your on your occur can also ulcers These 1 s of a toe, foot, or leg). foot, s of a toe, ely 25% of diabetics will develop a foot ulcer in their lifetime. ulcer a foot ely 25% of diabetics will develop Approximat More than 50% of diabetic foot ulcers return within 3 years. return ulcers 50% of diabetic foot than More and may infected can quickly become ulcers diabetic foot If left untreated, (los an amputation lead to

Keeping You Informed You Keeping • • •

Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound Foot ulcers may be caused by poor blood flow to your toes, soles, heels, and toes, your to flow poor blood be caused by may ulcers Foot causes tingling, which damage), (nerve also be neuropathy may ankles. There of loss This foot. in your or weakness feeling, of loss pain (burning or stinging), Poor heat, pain, or injury. of cold, awareness your decreases feet in your feeling This and toes. feet the shape of your can change damage and nerve blood flow and become down which can break foot, parts on certain of your pressure places ulcers. foot What Causes Diabetic Foot Ulcers? Ulcers? Diabetic Foot What Causes are breaks in the skin, most often on the ball of the foot, in skin, most often in the of the foot, on the ball breaks are ulcers foot Diabetic sugar). (high blood with diabetes someone What Is a Foot Ulcer? a Foot What Is Definition and Causes and Definition heels, sides, between your toes, or on the top of your feet. feet. of your on the top or toes, your heels, sides, between

Your Diabetic Foot Ulcer 5 Normal foot Diabetic foot ulcer Diabetic foot Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound Your health care provider will use a scale to describe the stage or grade of or grade stage describe the a scale to will use provider health care Your depth, appearance, ulcer’s your will explain grade The ulcer. diabetic foot your treatment. your determine and will help amount of infection and drainage, How Severe Is Your Foot Ulcer? Foot Is Your Severe How Your Diabetic Foot Ulcer 6 SAMPLE gery to to gery our health care our health care our health our health eet daily eet daily eet daily essure off essure our wound as our wound our wound as our wound sure off (offloading off (offloading sure Follow up with y Follow Wear corrective shoes or take shoes or take corrective Wear the pres devices) f your Check y for Care need sur may You deformity foot correct months 3 every provider Wear corrective shoes or corrective Wear pr the take f your Check y for Care y up with Follow instructed Wear corrective shoes corrective Wear f your Check up with y Follow on offloading devices (See 12) page instructed 3 months every provider care care provider regularly regularly provider care

• • • Do What to • • • • • • • • • Do What to What to Do What to olving s, y present Ulcers Extend into Tendon, Bone, or Capsule Tendon, into Extend Ulcers Superficial Ulcer of Skin or Subcutaneous Tissue of Skin Superficial Ulcer Intact Skin oot deformity oot deformity Foot deformit Foot inv Deeper ulcer and muscle but ligaments no bone or abscess Sensation absent Sensation absent rednes Warmth, No prior history of ulcer of ulcer No prior history or f swelling, pain, or discharge pain, or discharge swelling, on your be present may surface skin’s No history of ulcer No history ulcer No obvious present sensation Foot Diagnosis of diabetes

• Signs/Symptoms • • • • Signs/Symptoms • • • Signs/Symptoms • • Stage/Grade 2 Stage/Grade Stage/Grade 1 Stage/Grade Stage/Grade 0 Stage/Grade Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound Wagner Classification System for Diabetic Foot Ulcers Ulcers Foot Diabetic for System Classification Wagner Your Diabetic Foot Ulcer 7 emoval of emoval ement or e for your wound wound your e for e for your wound wound your e for e for your wound wound your e for heck your feet daily feet heck your heck your feet daily feet heck your ou may need surgery to to need surgery ou may ou may need surgery to to need surgery ou may ollow up with your health up with your ollow ollow up with your health health up with your ollow Medical manag F frequently provider care Debridement (r bone and/or dead tissue) if indicated Car as instructed hospitalization possible Y molded shoes or take off the pressure devices) (offloading C Car as instructed Y deformity foot correct C Car Y F every provider care 3 months W off the pressure or take devices) (offloading as instructed deformity foot correct

• • • • • Do What to • What to Do What to • needcustom ou may • • • • What to Do What to • shoes corrective ear • y be present er involving er involving Gangrene and Infection and Gangrene Partial Foot Gangrene Foot Partial Deep Ulcer with Osteomyelitis or Abscess with Osteomyelitis Ulcer Deep osis (tissue death) or osis (tissue dvanced infection with infection dvanced oot deformity oot deformity oot deformity present oot deformity A necrotic and/or drainage and gangrene tissue Sensation ma gangrene (advanced tissue tissue (advanced gangrene death) present usually present Necr Sensation absent F ligament and muscle with and muscle with ligament (infection) an abscess (bone or osteomyelitis infection) F Deeper ulc Sensation absent Sensation

Signs/Symptoms • • • • • Signs/Symptoms • • Signs/Symptoms • Stage/Grade 5 Stage/Grade Stage/Grade 4 Stage/Grade Stage/Grade 3 Stage/Grade Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound Your Diabetic Foot Ulcer 8 The test is just like is just like test The 5

4 SAMPLE ts, and braces) ts, and braces) and to hear the sound of blood flowing sound of blood flowing hear the and to es) al or vascular surgeon surgeon al or vascular Compares the blood pressure the blood pressure Compares pressure: ABI) or toe may include: may sel) assessment es in foot disorders) disorders) es in foot ysician Includes checking circulation (blood Includes checking circulation exam: and physical tory allergies to drugs and drugs allergies to conditions; or w of all medications, illnesses, having your blood pressure checked in your arm. A blood pressure cuff is arm. A blood pressure in your checked pressure blood your having for a little pressure feel may You and toes. foot, calf, thigh, on your placed in pressure blood Lower each measurement. for only about 60 seconds in the or blockage a narrowing indicate may than 0.9) the leg (an ABI less artery disease/PAD). legs (peripheral arteries in your at your ankle to the blood pressure in the upper arm. blood pressure the ankle to at your blood vessels. your through Uses a handheld w Doppler study: ( index Ankle-brachial

• • as needed and x-rays tests • Laboratory dressings; and reactions to anesthesia to and reactions dressings;

of infections history and your sensation (feeling), flow), Nutritionist (specializes in diet) Nutritionist (specializes Wound specialist and gener Wound Orthotist molded shoes, suppor (fits custom Podiatrist (specializ Podiatrist Primary care ph care Primary in diabet Endocrinologist (specializes Vascular (blood ves Vascular Revie Complete his Complete

• • • • • • • • • his team may recommend and perform all or some of your tests and exams. tests all or some of your and perform recommend may his team Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound Your tests and exams may include: may and exams tests Your T and Exams Tests

You will often have a team of health care providers working with you to keep your your keep to with you working providers of health care a team will often have You including: healthy, feet Testing and Diagnosis and Testing Your Diabetic Foot Ulcer 9

It is important 7 An HbA1c level measures your your measures An HbA1c level of blood sugar level average 3 months. the past 2 to over of 6.5% or higher A level diabetes. indicates Results Results of level A blood glucose per (milligrams mg/dL 126 or higher afterdeciliter) diabetes. indicate may fasting (including Other conditions blood elevate may stress) temporarily, levels glucose a repeat order may so a doctor a diagnosis confirm to test of diabetes. of level A blood glucose or higher 200 mg/dL diabetes. indicates 6 Instructions not eat or drink should You A this test. before 8 hours for through is taken blood sample arm. in your a vein drink a solution You g of glucose. 75 containing A blood sample is taken arm in your a vein through later. 2 hours usually eat and may You A blood test. this drink before stick finger by sample is taken arm. in your a vein or through est that a reduction in HbA1c by 1% was associated with a associated 1% was in HbA1c by est that a reduction ose before a meal: 80 to 130 mg/dL a meal: 80 to ose before o 2 hours after beginning of the meal: lower than 180 mg/dL 180 mg/dL than after of the meal: lower beginning o 2 hours Gluc 1 t eduction in the risk of amputation or death from PAD. eduction in the risk of amputation or death from ou monitor your blood sugars very closely when you have an open have closely when you very blood sugars your ou monitor

• • glucose monitor. Your health care provider will tell you what type of monitor of monitor what type you will tell provider health care Your monitor. glucose often and how finger, your a blood sample from collect to need, how you following the suggests Association Diabetes American The should test. you adults with diabetes: most non-pregnant for targets Y the main tests used to diagnose diabetes diagnose to used tests the main

F diet, nutrition, and fluid intake of your Review

ound and work with your health care provider to heal your wound. heal your to provider health care with your ound and work

here is no evidence that controlling blood glucose prevents ulcers, but ulcers, prevents blood glucose that controlling is no evidence here • at home with a levels blood glucose check your alsoneedto ou may • are test HbA1c , and test tolerance glucose oral test, glucose plasma asting •

Test plasma Fasting test glucose glucose Oral test tolerance HbA1c (hemoglobin A1c or glycated hemoglobin) test w that y some studies sugg 43% r K T Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound

Informed eeping You Your Diabetic Foot Ulcer 10 The The 8 SAMPLE Charcot foot Charcot osis)?

9 ed? status of the wound? Charcot foot Charcot xposed bone? Check for the risk of more serious conditions, such as serious conditions, the risk of more for am: Check oul odor or drainage? oul odor or drainage? A weakness of the bones and a flattening of the foot caused of the foot bones and a flattening of the oot: A weakness , red, or pink? or pink? , red, This may be present if you if you be present may of the bone): This (an infection yelitis ements is always taken with your foot in the same position. in the foot your with taken is always ements - Yellow - Black: death of cells in tissue (necr in tissue - Black: death of cells Normal foot

be osteomyelitis Other causes may damage). (nerve neuropathy by offthe foot pressure take is to treatment The surgery. foot or recent some deformities. help correct be needed to may Surgery (offloading). can see the bone, the bone feels rough or soft, or the ulcer has failed to to has failed or soft, or the ulcer rough can see the bone, the bone feels is until the infection is unlikely ulcer diabetic foot heal. Healing of your controlled. Is there any e any Is there f any Is there Where is the wound locat is the wound Where depth? and size What is the What is the color/ Charcot f Charcot Osteom

• • • • • • • following questions are asked: questions are following A complete examination of your ulcer and wound and wound ulcer your of examination A complete examination: Ulcer measur osteomyelitis and Charcot foot. and Charcot osteomyelitis

Detailed foot ex Detailed foot

• • Your Diabetic Foot Ulcer Diabetic Foot | Your Ulcers Home Skills Kit: Diabetic Foot Wound

Treatment

Treatment Options Pain Control Removing Pressure Non-Medication Strategies (Offloading) ...... 12. for Pain ...... 15 Foot Care ...... 12 Medication for Mild-to- Moderate Pain ...... 15 Nutrition Medication for Nerve Pain . . . . 16. What to Eat ...... 13 Narcotics or Opioids for How Much to Eat ...... 14 Severe Pain ...... 16. SAMPLE Treatment Options

This chapter will include ways to remove pressure, perform foot care, eat a healthy diet, and manage pain.

Removing Pressure (Offloading) Depending on the grade or stage of your ulcer, your health care provider may recommend a variety of pressure-relieving (offloading) devices:

• If the ulcer is on the sole (bottom) of your foot, your health care provider may recommend a total contact cast (TCC) or a fixed ankle walking boot.10-11 These devices meet the standard for relieving pressure on the sole or bottom of the foot by at least 30%.12 • If you have a draining wound that requires frequent dressing changes, you may need to use a removable walker boot or other specialized offloading device.

Treatment

Removable boot

Foot Care • Check your feet each day . Look for changes in color, swelling, skin cracks, pain, or numbness. • Check the skin on the top of your foot, between each toe, and the soles and heels of your feet. Use a mirror if needed. • Check calluses and corns . If your doctor approves, use a pumice stone to keep calluses under control. Do not use sharp objects or chemicals to remove them.

Wound Home Skills Kit: Diabetic Foot Ulcers | Treatment 12 • Wash your feet daily using mild soap and water. Dry carefully, especially between your toes. • Do not use hot water . Decreased feeling (neuropathy) in your nerves may cause you to not feel your feet. Hot water can also burn your skin. • Keep your nails trimmed . Ask for help if you need it to avoid cutting your skin. • Avoid going barefoot or wearing shoes without socks. • Choose shoes that are the correct size. The best time for buying shoes is in the afternoon. • Have your feet checked at each visit to your doctor.

Treatment

Nutrition

Eating right can help prevent limb loss in diabetic patients.13 You can use this form to find out if you are eating a healthy diet: mna-elderly.com/forms/Self_ MNA_English_Imperial.pdf.

What to Eat A healthy diet can also promote wound healing and should include:14

• Protein and iron—important for tissue repair and can be found in meats, poultry, eggs, fish, and nuts • Some meatless sources of protein, including: • Beans • Quinoa—a grain substitute for rice • Soy—a vegetarian option that often comes in the form of tofu

Wound Home Skills Kit: Diabetic Foot Ulcers | Treatment 13 • Peanut butter—also provides healthy fats and SAMPLEessential amino acids • Buckwheat—can be ground into flour and also eaten as oatmeal • Calcium—dairy products and leafy greens are generally high in this nutrient • Vitamins A, C, E and K—important for skin repair and can be found in lean meats, fruits, vegetables, dairy, and whole grains • Drinking 8 cups of water or other beverages each day—it is important to make sure you’re getting enough fluids

How Much to Eat A healthy diet should include 30 to 35 calories (energy intake) for every kilogram (kg) of your body weight. You can find out how many calories you need each day by using the calculation tool below.

Daily Calorie Calculation Tool Your Weight (lbs.)

Divide by 2.2 Treatment Multiply by 30 Total

Example 150 lbs. = 68 kg x 30 cal. = 2,040 calories/day 2.2

Weigh yourself daily and adjust your calories if you gain or lose weight. Your health care provider can request that you consult with a dietitian if you have difficulty managing your weight, eating, have dietary restrictions, or have any medical conditions with special diets.

Stop smoking if you are a smoker. The chemicals in cigarettes interfere with your blood flow and your skin healing. For help, you can view The American College of Surgeons Quit Smoking before Surgery brochure and Quit Plan online at facs.org/quitsmoking.

Wound Home Skills Kit: Diabetic Foot Ulcers | Treatment 14 Pain Control

Diabetic foot ulcers may be very painful. Your doctor will work with you to develop a pain control plan. Be sure to mention any pain medication you are already taking and how you managed pain in the past.

Non-Medication Strategies for Pain • Offload or take pressure off your ulcer whenever possible. • Keep your bed linens smooth and unwrinkled. • Request a time-out or rest period during your wound care or any procedure that causes pain. • Keep your ulcer covered and moist, and use a non-stick dressing. • Use distraction (music or games) and guided imagery to direct your focus away from your pain.15

Treatment

Distraction

Guided imagery

Medication for Mild-to-Moderate Pain • Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Motrin®, Advil®), and naproxen (Aleve®) are used to treat mild-to-moderate pain. • Plan to take your pain medication 30 minutes before your wound care. • Possible side effects include stomach upset, bleeding in the digestive tract, and fluid retention.

Wound Home Skills Kit: Diabetic Foot Ulcers | Treatment 15 Medication for Nerve Pain SAMPLE • Medications such as gabapentin (Neurontin®) and pregabalin (Lyrica®) are used to prevent nerve pain by calming over-active nerves. • Possible side effects include dizziness, drowsiness, suicidal thoughts, and swelling in your hands and feet.

Narcotics or Opioids for Severe Pain • Opioids are used to treat moderate-to-severe pain. Severe pain means you can’t focus or sleep because you can’t take your mind off your pain. • Examples include tapentadol (Nucynta®), tramadol (Ultram®), hydrocodone (Norco®), oxycodone (OxyContin®), and oxycodone with acetaminophen (Percocet®, Percodan®). • Side effects include sleepiness; lowered blood pressure, heart, and breathing rates; skin rash and itching; nausea; constipation; and difficulty urinating. You may also become physically dependent or addicted to opioids.

• If you have pain lasting for several weeks or longer, a treatment plan will be Treatment developed to help ensure best pain management practices. Go to facs.org/safepaincontrol for more information on safe and effective pain control.

Pain Management Guide How Intense Is My Pain? What Can I Take to Feel Better?

• I hardly notice my pain, and it does Non-medication therapies not interfere with my activities. + • I notice my pain and it distracts me, Non-opioid, oral medications but I can still do activities (sitting up, You may take these to control mild-to- walking, standing). moderate pain when needed

Non-medication therapies • My pain is hard to ignore and is + more noticeable even when I rest. Non-opioid medications • My pain interferes with my You may be told to take them usual activities. regularly throughout the day rather than as needed

• I am focused on my pain, and I am Non-medication therapies not doing my daily activities. + • I am groaning in pain, and I cannot Around-the-clock non-opioid medications sleep. I am unable to do anything. + • My pain is as bad as it could be, Short-acting opioids (for a few days) and nothing else matters. Call your surgeon if your pain continues

Wound Home Skills Kit: Diabetic Foot Ulcers | Treatment 16 Wound Care

Wound Cleaning Dressings and Bandages Cleaning Your Wound ...... 18 Gauze Dressings ...... 22 Goals of Cleaning ...... 18 Dressings by Wound Type . . . . 24 Cleaning Your Wound Skills . . . 18 Dressing Skills ...... 26 Packing Your Wound Wound Packing Skills ...... 28 SAMPLE Wound Cleaning

This chapter will include instructions on cleaning your wound, types of dressings and bandages, removing a dressing, putting on a new dressing, and packing a wound. Cleaning Your Wound • Most wounds should be cleaned at least once each day. Follow the instructions of your wound care provider. Some dressings are designed to stay in place for 2 to 3 days. Clean all of your skin in the shower daily if allowed by your health care provider. • A bandage or dressing should be applied if the wound is draining or needs protection. • Your health care provider will determine if unhealthy tissue should be removed (debrided) from your wound.

• Wounds should be debrided only by a health care provider using special tools. Wound Care You should not try to debride your wound, as you can cause harm and make the wound larger. • There are also bandages and dressings treated with medications that promote debridement when applied directly to the wound.

Goals of Cleaning • To remove bacteria from the wound surface • Inspect the wound • Protect the healing wound

Cleaning Your Wound Skills • These are general instructions for cleaning a wound. Follow any special instructions you may also receive from your health care Watch provider for cleaning your wound. and Review • Watch the Cleaning Your Wound video online at facs.org/woundcare, and then follow each of the steps .

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 18 SKILL Gathering Your Supplies

• Drinking (tap) water or normal saline 0.9% • A mild cleansing solution, if advised, like Dove® or Ivory®16 • Clean gloves • Dressing material • Tape or a bandage • Clean gauze or a clean towel • Scissors • Cotton swabs (Q-tips®) • A small plastic bag Wound Care

SKILL Preparing Your Work Area

• If your hands are visibly dirty, wash your hands with soap and water for 15 to 30 seconds. If your hands are not visibly dirty, you may use a 60% alcohol-based hand gel. • Put a clean towel over your work area and set a clean bowl on it. • Pour water or saline into the bowl. • Open any dressing packages so you can easily remove the contents later. • Clean tweezers or scissors with alcohol or an alcohol wipe before using.

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 19 SKILL Removing Your Old Dressing SAMPLE

• If the dressing is dry or is stuck to your wound, moisten it with normal saline to loosen it before removing. • Loosen the tape on the dressing but don’t remove the dressing yet. • Put on a medical glove or use a plastic bag over your hand to grasp and remove the dressing. • Check the color and amount of the drainage. • Place the dressing and the glove/bag in a second sealed plastic bag and discard. Wound Care

Moisten your wound with saline to remove all pieces of an old dressing

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 20 SKILL Cleaning Your Wound

• Use a 60% alcohol-based hand gel to clean your hands again. • Put on clean gloves. • Soak a new gauze or clean towel with water or saline and apply the cleaning solution, if advised.17 • Starting at the center of the wound, work in a circular pattern and clean toward the edges. Do not return to the wound center after cleaning to avoid recontamination of the wound. • Remove any loose tissue with the gauze pad. • Do not press hard or scrub a clean wound because this can damage the

tissue and slow healing.18 Wound Care • Wet a new gauze or towel with water or saline to rinse off any cleaning solution. Start at the center and work out to the edges. • Use a new gauze or towel and a mild skin cleanser and water to clean periwound maceration (skin around the wound broken down by moisture).19 • Use a dry gauze or towel to gently pat around the wound to dry completely. Warning: Use the products below only if advised by your health care provider:20

• Hydrogen peroxide can be harmful to tissues even at low concentrations.21 • Iodine products should be used with caution if you have renal (kidney) failure, history of thyroid disorders, or known iodine sensitivity. • Sodium hypochlorite (Dakin’s solution) can be harmful even at low concentrations. A solution labeled no greater than 0.025%, may be advised for short periods only when no other option is available.

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 21 SAMPLE Dressings and Bandages

The correct dressing depends on the wound type, stage, and size, as well as your health condition. As your wound heals, you may need to change to a different type of dressing. If you have complications, your health care provider can help you choose the right dressing.

Wound dressings are used to:

• Keep your wound moist • Protect your wound from infection • Remove drainage • Help your wound heal Wound Care

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 22 Gauze Dressings • Do not use dry gauze directly over open wounds . It can dry and stick to the wound and cause pain and damage when removed. • Use a single gauze strip/roll to pack deep ulcers and wound spaces. Small, single pieces can grow into the wound edge and become infected if not properly removed. • Gauze dressings may be used as the secondary (cover) dressing over a moist primary dressing. • Loosely woven gauze may be packed into deep or highly draining ulcers. • Tightly woven gauze is used for minimally draining ulcers. Wound Care

Loosely woven gauze

Tightly woven gauze

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 23 Dressings by Wound Type1 SAMPLE

Your Ulcer Goals Primary Secondary Precautions Dressing Dressing

• Early signs • Protect • Lotion • Usually not of injury or • Check • Transparent needed redness with frequently film no open skin • Prevent further • Hydrogel or drainage injury • Silicone foam

• Shallow pink • Protect • Transparent film If needed: • Use dressings or red ulcer that won’t • Keep moist • Silicone foam • Gauze • May have • Promote new • Hydrogel stick to or tear • Hydrocolloid your skin when closed blisters tissue growth • Hydrocolloid • Bulky gauze pad removing • May have • Prevent • Alginate or cause yellow callous infection • Foam growth with maceration no-to-low (skin drainage breakdown) or allergies • Count all foam pieces used Wound Care and removed from dressing • Deeper ulcer • Protect • Hydrogel • Bulky gauze • Avoid • Clean, red, • Prevent • Foam dressing bandages moderate-to- infection • Alginate • Foam and tape that cause high drainage • Pack empty • Manuka honey22 • Super absorbent wound spaces dressing maceration • Negative (skin • Promote pressure wound breakdown) healthy tissue therapy (pg . 31) or allergies growth • Count all foam • Manage pieces used drainage and removed from dressing

• Mixed yellow • Protect • Hydrogel • Bulky gauze • Avoid and red, with • Reduce • Antiseptic- dressing bandages slough (dead, bacteria treated foam • Foam and tape separating • Manage • Alginate • Super absorbent that cause tissue) maceration drainage • Silver dressing present (skin • Control odor • Manuka honey • Infected breakdown) • Pack empty • Iodine or allergies • Minimal- wound spaces to-heavy • Hydrofiber® • Count all foam drainage • Negative pieces used pressure wound and removed therapy (pg . 31) from dressing

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 24 Your Ulcer Goals Primary Secondary Precautions Dressing Dressing • All slough • Remove slough • Hydrogel • Bulky gauze • Use a dressing (dead • Keep moist • Hydrofiber® dressing that helps separating • Manage • Antiseptic- • Foam remove the tissue) is drainage treated foam • Super absorbent slough and yellow, white, absorbs • Alginate dressing tan, or gray drainage • Manuka honey • Moderate • Avoid to heavy • Hydrocolloid bandages infection and • Negative and tape drainage pressure wound that cause therapy (pg . 31) occlusion, maceration (skin breakdown), or allergies • Count all foam pieces used and removed from dressing Wound Care

• Eschar (dead • Protect • Hydrogel, • Bulky gauze separating • Minimize Hydrofiber® dressing tissue) is infection • Saline- or • Foam black, brown, • Professionally antiseptic- • Super absorbent or gray and debride if treated gauze dressing may be wet necessary • Alginate with infection • Cadexomer or dry and iodine if lifted prescribed

• Necrotic toes • Leave exposed • None* • None • *If the edges to air and of your toes allow to dry so are moist, an the toes can iodine dressing separate or can be applied be surgically to fight removed infection or reduce pain • A dry secondary dressing such as gauze can be used

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 25 Dressing Skills SAMPLE • Your health care provider may advise or prescribe a specific type of dressing for you to use. The chart on the previous page and Watch the online video will help you understand the different types of and dressings used for different wound conditions. If your wound is not Review healing, you may want to consult a wound care specialist. • Watch the Dressings and Bandaging video online at facs.org/woundcare, and then follow each of the steps .

SKILL Gathering Your Supplies

• Packing material, water, or solution prescribed by your doctor • Clean gloves

• A clean bowl Wound Care • Scissors • Tweezers • A clean towel • Outer dressing material to use as a bandage • Tape • Cotton swabs (Q-tips®) • A small plastic bag • Alcohol wipes

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 26 SKILL Preparing Your Work Area

• If your hands are visibly dirty, wash your hands with soap and water for 15 to 30 seconds. If your hands are not visibly dirty, you may use a 60% alcohol-based hand gel. • Put a clean towel over your work area and set a clean bowl on it. • Pour water or saline into the bowl. • Open any dressing packages so you can easily remove the contents later. • Clean tweezers and scissors with alcohol or an alcohol wipe before using.

SKILL Putting On a New Dressing

• Apply a moist dressing over a clean wound. Wound Care It is the first layer that absorbs drainage from the wound. • Wrap a secondary gauze bandage 1 inch past the dressing in all directions to make sure it is completely covered. • Tape the dressing. Tape the end of the bandage to the bandage itself to hold it in place without tearing the skin.

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 27 SAMPLE Packing Your Wound Wound Packing Skills • If a wound is deep or tunnels, it will need to be packed to absorb drainage and help it heal. Watch and • Your health care provider will let you know if you need to pack Review your wound and how to order wound packing supplies. • Watch the Packing Your Wound video online at facs.org/woundcare and then follow each of the steps .

SKILL Packing Your Wound

• Cut pieces of tape longer than the length and width of the wound to secure the dressing. Hang one end of the tape from the edge of a table or

workspace until needed. Wound Care • Carefully remove any tape or unwrap the bandage. Cover your hand with a plastic bag or a glove to remove the existing bandage. Check the bandage for drainage or odor, place it in a second bag, and discard. • Use a 60% alcohol-based hand gel for removing germs from your hands. • Put on clean gloves. • Use clean tweezers to lift the packing out of the container. Cut off the amount needed and place it on a clean piece of gauze. • Gently push the packing material into the wound to fill the wound space. Use a cotton swab, if needed, to push the packing beneath any tunneled areas. You may also use a cotton swab to gently measure the depth of the wound and record it each day. • Open the outer dressing material package and place the dressing over the packing and wound site. • Tape the outer dressing in place or wrap a bandage around the wound area to hold the dressing in place. • Remove your gloves and discard. • Use a 60% alcohol-based hand gel to remove germs from your hands.

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 28 SKILL Packing Your Wound (continued)

1 Diabetic foot ulcer

Pack the ulcer 2 Wound Care

Packing in place

3 Cover with dry gauze

4 Secure with a toe sock

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 29 SAMPLE Notes

Wound Care

Wound Home Skills Kit: Diabetic Foot Ulcers | Wound Care 30 Negative Pressure Wound Therapy

Negative Pressure Wound Therapy (NPWT) Applying NPWT ...... 32 Home Management of NPWT . . 33 Risks and Safety Information . . . 36 SAMPLE Negative Pressure Wound Therapy

If your wound is infected or has a high amount of drainage, you may need to have a type of dressing called negative pressure wound therapy (NPWT). This therapy has been effective for the treatment of some diabetic foot ulcers.23 NPWT uses a sealed wound dressing connected to a vacuum pump. NPWT helps draw wound edges together and promotes the regrowth of healthy tissue. This helps increase blood flow to the area and removes excess fluid from the wound. NPWT can be used for a few days to several months.

A medical supply company will set up rental of the equipment and will usually deliver the vacuum pump supplies to your home. A health care provider will Negative Pressure Wound Therapy change the dressing on a scheduled basis.

NPWT Supplies

Vacuum pump Foam dressing and tubing

Applying NPWT 1 . The wound is cleaned and debrided, if needed.

2 . A foam dressing or filler material is fitted to the shape of your wound. The foam can be many colors, including blue, gray, or white.

3 . A protective dressing may be added to the healthy skin around your wound.

4 . The foam is sealed with a clear film.

5 . The drain tubing is connected to an opening in the film and attached to a canister.

6 . The canister is then attached to a vacuum pump.

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 32 1 2

Open wound before NPWT Foam dressing fitted to your wound

3 4 Negative Pressure Wound Therapy

Tubing attached to a canister Canister attached to vacuum pump

Home Management of NPWT When your NPWT supplies are delivered, the supplier should tell you: • How to contact them for equipment problems through a support number available 24 hours a day/7 days a week • How to access supplier staff for 24/7 technical product questions/information • To call your health care provider or 911 if a medical emergency arises

Things to know: • The first time the pump is turned on, you may feel a slight pulling sensation. • The dressing will pull down against your skin when the therapy is working, and it will also be firm to the touch. • The dressing will be changed by a health care provider, usually every 3 to 7 days, depending on the size, type, and amount of drainage. • You may experience some pain during dressing changes . You may need to take pain medication 30 minutes before your dressing change.24 • Most NPWT systems are portable so that you can move around, so ask your health care provider how much activity you should be doing. • Make sure that the pump is positioned so it cannot be pulled off onto the floor during sleep.

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 33 Daily checks SAMPLE Check your dressing and NPWT daily to make sure: • The negative pressure seal is not broken and leaks are at a minimum • There are no kinks in the tubing • The drainage chamber is filling and does not need to be changed • The skin around the dressing has not changed • The dressing is clean • The drainage level in the canister is not full Negative Pressure Wound Therapy Low battery If the therapy pump is battery operated, change the batteries when the battery indicator flashes. To change the batteries:

1 . Press the button to pause the therapy.

2 . Take the battery cover off from the pump and put in new batteries.

3 . Put the cover back on and press the start button to continue your therapy.

Low vacuum alarm or light flash This means there may be an air leak around the dressing. 1 . Smooth the dressing and strips to ensure there is no way for air to get in.

2 . Press the button to restart the vacuum pump.

3 . The alarm will also sound if the canister is full or if the tubing is kinked or blocked. Change the canister if it is full and you were trained to do so. The canister is usually changed with your dressing.

4 . If the tubing is kinked or blocked, try to straighten it out.

5 . Removing the kink or blockage should stop the alarm. Notify your supplier if the alarm does not stop.

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 34 Disconnecting, shutting off, and restarting You will disconnect the pump to take a shower or use the toilet. If you feel more comfortable with assistance, you may want to organize your shower times around the days that you have a home health provider visit.

1 . Press the button to pause the therapy. There should be a connector built into the tubing between the pump and dressing.

2 . Holding the tubing pointing up, disconnect the two parts of the connector. Place the pump somewhere safe.

3 . The dressing on top of the wound is water-resistant. You can shower or wash with the dressing in place, but do not soak the dressing or it may fall off. Point Negative Pressure Wound Therapy the end of the tubing attached to the dressing down so that water cannot enter the tube.

4 . When you are ready to reconnect the pump, connect the two halves back together. Make sure the dressing is smoothed down and has no creases that could cause air leaks.

5 . Press the button to restart the pump, and a light will flash to show that the pump is starting to apply therapy.

Shutting off • If the therapy off button is accidentally turned off, push the same button to turn the unit back on. • The system should not be off for more than 2 hours each day.

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 35 Risks and Safety Information SAMPLE Bleeding If you have recently had surgery on your heart or blood vessels, or are taking blood thinners, you may have a higher risk of bleeding, whether you are using NPWT or not.

If you see a sudden increase or a large amount of blood from your wound in the tubing or canister:

1 . Turn OFF the therapy unit right away .

2 . Do not remove your dressing. Negative Pressure Wound Therapy

3 . Apply pressure over the area with gauze or a clean towel.

Call 911 (or local emergency number) and then notify your health care provider .

Wound infection Call your health care provider right away if you think your wound is infected or if you have any of the following symptoms: • Fever of 101°F (38.3°C) • Your wound has pus or a bad smell • Your wound is sore, red, or swollen • Your wound has increased drainage • Your skin itches or you have a rash • You have elevated blood sugar • The wound or the area around the wound feels very warm

Serious infection A wound infection can spread through the rest of your body. Call your health care provider right away if you have any of the following symptoms: • Vomiting or diarrhea • Headache • Confusion • Feeling faint or dizzy • Sore throat • A fever of 102°F when you stand up (39°C) • Rash

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 36 Allergic reaction Therapy dressings, drapes, and canisters are latex-free and are delivered sterile. Use these items only once. At the end of therapy, follow directions for waste disposal or recycling. It is possible to have a sensitivity or allergic reaction to other wound care products. Call your health care provider right away at the following signs:

• Rash or hives • Redness • Swelling • Severe itching

If you have difficulty breathing, seek immediate emergency medical Negative Pressure Wound Therapy assistance . Call 911 (or your local emergency number) .

Expiration date Check the expiration date on all parts of the equipment. Do not use it if they are expired. Devices can degrade over time. If your equipment is expired, contact your medical supplier to request a replacement.

Negative pressure wound therapy

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 37 SAMPLE Notes

Negative Pressure Wound Therapy

Wound Home Skills Kit: Diabetic Foot Ulcers | Negative Pressure Wound Therapy 38 Resources

Home Care Planning ...... 40 Disclaimer ...... 45 Wound Care Resources . . . . . 41. Acknowledgments ...... 46 References ...... 42 Evaluation Consent ...... 48 Check Your Knowledge . . . . . 44. SAMPLE Home Care Planning

To make sure you are ready to go home, you and anyone helping with your care should review the Skills Checklist for your wound care and the Discharge Checklist with your health care provider. You should be able to explain and demonstrate all parts of your care before you go home.

Supplies may be ordered through a local medical equipment store or pharmacy or national Internet order company. Have any supplies you need ordered before you leave the hospital. It may take 1 to 2 days for them to arrive. Leave the hospital with several days of wound supplies in case there is a delay.

You may need to have prescriptions filled for medication or wound dressings. If you will have home health care, they may be assigned to order your supplies. Your hospital discharge planner can help with the specific Resources details for the coverage of the supplies you need. They can also assist you with setting up delivery of supplies if you need negative pressure wound therapy.

At any point in your care, you can refer to this booklet to review your instructions as well as your checklists and the videos for skill instructions at facs.org/woundcare.

• Lacerations and Abrasions • Cleaning Your Wound • Packing Your Wound • Dressings and Bandaging • Your Surgical Drain • Negative Pressure Wound Therapy

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 40 Wound Care Resources

Founding Organization American College of Surgeons Surgical Patient Education Program 800-621-4111 facs.org/patienteducation

Collaborative Organizations American Burn Association ameriburn.org American College of Surgeons Advisory Council for General Surgery, Advisory Council for Pediatric Surgery, and Advisory Council for Plastic and Maxillofacial Surgery facs.org American College of Wound Healing and Tissue Repair acwound.org/college

American Association for the Surgery of Trauma Resources aast.org American Society of Plastic Surgeons plasticsurgery.org Association of periOperative Registered Nurses (AORN) aorn.org Wound Healing Society woundheal.org Wound, Ostomy and Continence Nurses Society™ (WOCN®) wocn.org

Additional Resources Advanced Tissue advancedtissue.com/the-best-and-worst-ideas-for-open-wounds Association for the Advancement of Wound Care (AAWC) Wound Patient/Caregiver Resources aawconline.org/wound-patientcaregiver-resources National Pressure Ulcer Advisory Panel (NPUAP) npuap.org

WOCN® Society™ Patient Information section wocn.org/?page=PatientResources

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 41 SAMPLE References

1. Gupta S, Anderson C, Black J, et al. Management of Chronic Wounds: Diagnosis, Preparation, Treatment, and Follow-up. Wounds. 2017 Sep;29(9):S19-S36.

2. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005 Jan 12;293(2):217-228.

3. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, et al. The global burden of diabetic foot disease. Lancet. 2005 Nov 12;366(9498):1,719-1,724.

4. Schaper NC, Andros G, Apelqvst J, et al. Specific guidelines for the diagnosis and treatment of peripheral artery disease in a patient with diabetes and ulceration of the foot 2011. Diabetes Metab Res Rev. 2012 Feb;28 Suppl 1:236-237. doi: 10.1002/ dmrr.2252.

5. The Society for Vascular Surgery. Ankle-Brachial Index or ABI Test website. https:// vascular.org/patient-resources/vascular-tests/ankle-brachial-index-or-abi-test. Accessed July 31, 2017.

6. Grout J. Understanding Your Lab Test Results. Diabetes Self-Management Resources website. https://www.diabetesselfmanagement.com/about-diabetes/diabetes-basics/ understanding-your-lab-test-results. Accessed on July 10, 2018.

7. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000 Aug 12;321(7258):405-412.

8. Flanagan M. Improving Accuracy of wound measurement in clinical practice. Ostomy Wound Manage. 2003;49(10):28-40.

9. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot Foot in Diabetes. Diabetes Care. 2011 Sep;34(9):2123-2129. Published online 2011 Aug 19. doi: 10.2337/dc11- 0844.

10. Lewis J, Lipp A. Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD002302. doi: 10.1002/14651858. CD002302.pub2.

11. Lavery LA, Higgins KR, La Fontaine J, et al. Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers. Int Wound J. 2015 Dec;12(6):710-715. doi: 10.1111/iwj.12213. Epub 2014 Feb 21.

12. Bus SA. The Role of Pressure Offloading on Diabetic Foot Ulcer Healing and Prevention of Recurrence. Plast Reconstr Surg. 2016 Sep;138(3 Suppl):179S-1787S. doi: 10.1097/PRS.0000000000002686.

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 42 13. Gau BR, Chen HY, Hung SY, et al. The impact of nutritional status on treatment outcomes of patients with limb-threatening diabetic foot ulcers. J Diabetes Complications. 2016 Jan-Feb;30(1):138-142. doi: 10.1016/j.jdiacomp.2015.09.011. Epub 2015 Sep 26.

14. Advanced Tissue. Nutrition and Wound Care: Following a Wound Healing Diet. 2015 Advanced Tissue website. http://www.advancedtissue.com/download-our-free-wound- healing-nutrition-guide. Accessed July 31, 2017.

15. Gélinas C, Arbour C, Michaud C, et al. Patients and ICU nurses' perspectives of non-pharmacological interventions for pain management. Nurs Crit Care. 2013 Nov;18(6)307-318. doi:10.1111/j.1478-5153.2012.00531.x. Epub 2012 Oct 3.

16. Kestrel Health Information, Inc. Wound Cleanser Products. Wound Source Website. www.woundsource.com/product-category/wound-cleansers/wound-cleanser-products. Accessed on July 10, 2018.

17. Wound, Ostomy and Continence Nurses Society (WOCN) Wound Committee, et al. Clean vs. sterile dressing techniques for management of chronic wounds: A fact sheet. J Wound Ostomy Continence Nurs. 2012 Mar-Apr;39(2 Suppl):S30-4. doi: 10.1097/WON.0b013e3182478e06. Resources

18. Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan.

19. Konya C, Sanada H, Sugama J, et al. Skin debris and micro-organisms on the periwound skin of pressure ulcers and the influence of periwound cleansing on microbial flora. Ostomy Wound Manage. 2005 Jan;51(1):50-9.

20. Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev. 2013 Mar 28;(3):CD004983. doi: 10.1002/14651858.CD004983.pub3.

21. Lu M, Hansen EN. Hydrogen Peroxide Wound Irrigation in Orthopaedic Surgery. J Bone Jt Infect. 2017 Jan 1;2(1):3-9. doi: 10.7150/jbji.16690. eCollection 2017.

22. Kamaratos AV, Tzirogiannis KN, Iraklianou SA, et al. Manuka honey-impregnated dressings (MHID) in the treatment of neuropathic diabetic foot ulcers. Int Wound J. 2014 Jun;11(3):259-663. doi: 10.1111/j.1742-481X.2012.01082.x. Epub 2012 Sep 18.

23. Xie X, McGregor M, Dendukuri N. The clinical effectiveness of negative pressure wound therapy: A systematic review. J Wound Care. 2010 Nov;19(11):490-495.

24. Upton D, Stephens D, Andrews A. Patients' experiences of negative pressure wound therapy for the treatment of wounds: A review. J Wound Care. 2013 Jan;22(1):34-39. 10.12968/jowc.2013.22.1.34.

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 43 SAMPLE Check Your Knowledge

Question 1 Diabetic foot ulcers can occur: A . Only on the heels and soles of your feet B . On the heels, sides, between your toes, or on the top of your feet C . Only on the balls of your feet D . Only on your toes

Question 2 A stage/grade 2 foot ulcer has: A . No sensation, a foot deformity, and is a deep ulcer involving ligaments and muscle but no bone or abscess B . No obvious ulcer with foot sensation present but possibly a foot deformity C . A history of or current foot deformity and a deeper ulcer with infection D . An advanced infection with drainage and/or necrotic tissue and gangrene Resources

Question 3 If you have a draining ulcer, you may need to use one of these devices to offload the pressure on your foot while walking: A . A total contact cast B . A roll-on total contact cast system C . Just a dry dressing D . A removable cast walking boot

Question 4 Which of these are true about your wound care? A . Use tap water to clean your wound unless your health care provider recommends something else. B . If your hands are visibly dirty, wash your hands with soap and water for 15 to 30 seconds. If your hands are not visibly dirty, use a 60% alcohol-based hand gel. C . Debride (remove unhealthy tissue) yourself with each dressing change. D . When cleaning the wound, start at the center and work in a circular pattern, cleaning toward the edges.

Answers: Question 1: B Question 2: A Question 3: D Question 4: A, B, and D

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 44 Disclaimer

The information contained in this booklet and the patient education section of the American College of Surgeons (ACS) website does not constitute medical advice. This information is published as a communications vehicle: to inform and to educate the public about specific surgical procedures. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation. It is important to remember that each individual is different, and the reasons and outcomes of any operation depend upon the patient’s specific diagnosis, disease state or other medical condition.

The ACS is a scientific and educational organization that is dedicated to the ethical and competent practice of surgery; it was founded to raise the standards of surgical practice and to improve the quality of care for the surgical patient. The ACS has endeavored to present information for prospective surgical patients based on current scientific information; there is no warranty on the timeliness, accuracy, or usefulness of this content. Under no circumstances will the ACS be liable for direct, indirect, incidental, special or punitive, or consequential damages that result in any way from your use of this resource. Resources

© 2018 American College of Surgeons. All Rights Reserved.

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 45 Acknowledgments SAMPLE

ACS Surgical Patient Wound Management Home Skills Education Program Program Task Force

Director: Barbara Dale, RN, CWOCN, CHHN, COS-C Ajit K . Sachdeva, MD, FACS, FRCSC Director of Wound Care Quality Home Health Assistant Director: Livingston, TN Kathleen Heneghan, PhD, RN, PN-C John Daly, MD, FACS Manager: Co-Chair, Patient Education Committee Nancy Strand, RN, MPH Emeritus Dean, Temple University School of Medicine Administrator: Fox Chase Cancer Center Mandy Bruggeman Philadelphia, PA

William Ennis, DO, MBA, FACOS Patient Education Committee American College of Wound Healing and Tissue Repair Ajit K . Sachdeva, MD, FACS, FRCSC University of Illinois Hospital Resources & Health Sciences System John M . Daly, MD, FACS Chicago, IL Eileen M . Duggen, MD David V . Feliciano, MD, FACS David V . Feliciano, MD, FACS Professor of Surgery University of Maryland Shock Trauma Center Frederick L . Greene, MD, FACS Baltimore, MD B .J . Hancock, MD, FACS, FRCSC Gayle Gordillo, MD, FACS Dennis H . Kraus, MD, FACS Wound Healing Society The Ohio State University Michael F . McGee, MD, FACS Columbus, OH

Beth H . Sutton, MD, FACS Lisa Gould, MD, PhD, FACS Michael J . Zinner, MD, FACS Past-President Wound Healing Society Warwick, RI

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 46 B .J . Hancock, MD, FACS, FRCSC Vernon Miller, MD, PC, FACS Associate Professor GFT, Pediatric Surgery Hot Springs Memorial Hospital Winnipeg Children’s Hospital Thermopolis, WY Winnipeg, MB Richard Schlanger, MD, FACS Sandy Hughes, BSN, RN, CWOCN, COS-C Clinical Surgery, Associate Professor CareGroup Parmenter Home Care & Hospice The Wexner Medical Center Comprehensive Treasurer, WOCN® Wound Center at The Ohio State University Watertown, MA Columbus, OH

James Jeng, MD, FACS Eric A . Weiss, MD, FACS Director of Wound Care, Professor of Surgery, ACS Advisory Council Pillar Chairman, Disaster Subcommittee, Columbia Orange Park Medical Center American Burn Association St. Vincent’s Medical Center Clay County Mt. Sinai Healthcare System Jacksonville, FL New York, NY Resources David M . Young, MD, FACS Phyllis Kupsick, RN, MSN, CWOCN Professor of Surgery Past-President University of California, San Francisco WOCN® San Francisco, CA Albemarle, NC

Ellice Mellinger, RN, MS, CNOR Senior Perioperative Education Specialist AORN Denver, CO

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 47 SAMPLE Evaluation Consent

Your Input Is Valuable You and your family are important members of the health care team. In order to help you safely care for yourself or a family member or friend with a wound, you are being provided with the American College of Surgeons Diabetic Foot Ulcers Home Skills Kit. We would like you to help us make sure that this skill kit prepared you to provide the best care for yourself or someone with a wound. We are asking you to complete a short evaluation about your care. You should complete this evaluation after your first follow-up visit with a health care provider or surgeon. This visit usually happens 7 to 14 days after your procedure. If you choose to complete the evaluation, you have two easy options: • Mail: Fill out the printed evaluation included in this kit and mail it back in the enclosed envelope provided.

• Online: Visit our website, facs.org/woundcare. Look for the link to Complete Resources the Wound Care Patient Evaluation: We Need Your Opinion!

Some Information about the Evaluation • It will take about 5 minutes of your time. • Answering this evaluation may help someone with a wound in the future. • All answers will be seen only by the study investigator at the American College of Surgeons. • Only the group response will be reported (for example, the average time patients spent watching the videos was 20 minutes). • The group responses will help your surgical team know what else can be done to help you or someone else care for a wound after an injury or operation. • You may check the evaluation website for the updated summary of the responses. Any questions should be directed to: Nancy Strand, MPH, RN American College of Surgeons 312-202-5566 | [email protected]

Wound Home Skills Kit: Diabetic Foot Ulcers | Resources 48 The Wound Management Home Skills Program, developed by the American College of Surgeons Division of Education, is made possible in part by the generous support of education grants from: Smith and Nephew Corp ., Ethicon, and Acelity .

AMERICAN COLLEGE OF SURGEONS DIVISION OF EDUCATION Blended Surgical Education and Training for Life®